Land Disturbance Permit

2. Section 1
4. Date:
   Date:
6. Permit Location/Address
8. City
9. State
10. Zip Code
12. I am...
    -- Select One --Grading and Seeding OnlyGetting a Lot Ready for DevelopmentGrading for a Parking LotCutting in a Street
13. Items Required:
    • Land Disturbance Permit is required for any grading, excavating, filling or removing of soil, or paving, on any lot or parcel of ground, in excess of 1,700 square feet.
    • Must complete attached standard EPSC form unless an engineered grading and drainage plan has been required and includes EPSC measures.
15. General Description of Use and Construction Activity:
17. Parcel Square Footage/Acreage
19. Front Width
20. Rear Width
21. Left Depth
22. Right Depth
24. Total Square Footage/Acreage to be disturbed
25. Estimated Construction Cost
26. Start Date
27. Anticipated Completion Date
31. Section 2
33. Applicant Name
34. Email Address
36. Address
38. City
39. State
40. Zip Code
42. Phone Number
43. Fax Number
44. Applicant's Role

    Check all that apply

    1. Contractor
    2. Property Owner
    3. Lessee
    4. Other

46. If Contractor or Property Owner are different from the Applicant then fill in Sections 4 and/or 5

    If Disturbance will occur within City Right-of-Way then fill in Section 6

50. Section 3
52. I, the Applicant of this Permit, do hereby understand the following:
    1. This Permit will be issued when all Reviews have been approved.
    2. Erosion Prevention and Sediment Control Practices will be implemented during all phases of construction as defined in Ordinance #1991.
    3. Work cannot commence until the Permit is issued by the City of Danville Engineer's Office.
    4. This Permit is subject to conditions set forth by the City of Danville Engineer's Office in this Permit and applicable Ordinances.
    5. To the best of my knowledge all information given herein is true.
54. Applicant's Signature
55. Date:
    Date:
59. Section 4
61. If the Contractor is not the Applicant, fill in the Contractor's Information:
63. Contractor
64. Email Address
66. Address
68. City
69. State
70. Zip Code
72. Phone Number
73. Fax Number
77. Section 5
79. If the Property Owner is not the Applicant, fill in the Property Owner's Information:
81. Property Owner
82. Email Address
84. Address
86. City
87. State
88. Zip Code
90. Phone Number
91. Fax Number
95. Section 6
97. If any disturbance will occur in City Right-of-Way, please provide the following information:
99. Type of Encroachment:
    -- Select One --Residential EntranceCommercial EntranceGrading or ExcavationLandscaping
100. Location of any Road Closures
102. Date and Length of Road Closures
106. Standard EPSC Plan

     This Plan can serve as the Erosion and Sediment Control Plan if the following conditions are met:

     • Disturbs less than 1 acre, and
     • Adds less than 5,000 square feet of new impervious surfaces, and
     • Contains no critical slope or flood hazard areas

     Otherwise, a detailed EPSC plan, prepared by an appropriate professional will be required.

108. For plot plans, choose one of the following options:
110. 
112. The most appropriate, from the options below, is option:
     -- Select One --ABCDEFG
113. Or, a combination of Options
     -- Select One --ABCDEF
114. &
     -- Select One --ABCDEF

116. If Option G is selected, please submit a sketch by email to the City Engineer's Office

118. Does the site have a sinkhole, drainage inlet, drainage easement, or stream?
     -- Select One --YesNo
120. If yes, please describe the additional measures that will be taken to protect these features
122. Will excavated materials be stockpiled or used as fill on site?
     -- Select One --YesNo
124. If yes, describe the location of the stockpiling along with additional measures to protect adjacent properties or drainage features
Leave This Blank:


126. 1. Receive an email copy of this form.
127. Email address

     This field is not part of the form submission.

128. Submit

* indicates a required field